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33 Adjuncts to Wound Healing for Abdominal Wall Wounds
353
when possible prior to defi nitive closure or elective
operations.
When we are faced with chronic wounds of
the abdominal wall, our goal is to preserve as
much tissue as possible to maintain a functional
and dynamic abdominal wall. We prefer to
debride these wounds early to help convert a
chronic wound to an acute one. In the following
section we describe how we use the appearance
of normal tissue and methylene blue to thoroughly and equally debride the entire wound.
Surgical Debridement
Our goal in surgical treatment of abdominal
wounds is to debride any senescent cells and
remove any contamination from the wound. Our
role in wound debridement occurs once the
intra- abdominal process is controlled. The bacterial load of a chronic wound can promote the
prolonged infl ammatory response, which halts
the wound-healing process (Fig. 33.1 ). Previous
Fig. 33.1 Chronic abdominal wound. Please note the
biofi lm burden at the base of the wound. The rolled edges
and fi brinogranular tissue at the superior and lateral
wound edges
studies have shown that the majority of chronic
wounds (90%) contain biofi lm on the wound
surface. The biofi lm downregulates cell turnover, prevents antibiotic delivery, and prevents
the chronic wound from proceeding through the
normal stages of wound healing [ 7 – 9 ]. In efforts
to decrease the bacterial burden and remove the
biofi lm from an abdominal wound, the patient
should undergo surgical debridement in an
operative setting. Deep tissue cultures of the
wound should be taken prior to applying surgical prep to the wound site; this will determine
the presence of bacteria, fungus, or yeast in the
wound prior to debridement (Fig. 33.2 ). A thin
confl uent layer of methylene blue is then painted
along all surfaces of the wound. This will help
guide the surgeon in removing all biofi lm and
senescent cells from the wound bed, it is also
pertinent to remove a 2–4 mm rim of tissue from
the wound edges [ 10 ] (Figs. 33.3 , 33.4 , and
33.5 ). All foreign bodies, including sutures,
should be removed (Fig. 33.5 ). Colonized fas-
cial sutures must be removed if the fascia has
healed. If infected biologic or synthetic mesh
exists, it should be removed. If a sinus tract is
present in the wound, methylene blue can gently
be injected using an 18-gauge angiocatheter
inserted gently into the tract. Debridement
should then proceed using one or a combination
of the following modalities: scalpel, curette,
rongeur, or Versajet. The purpose of using methylene blue during the debridement is to remove
all biofi lm from the wound bed and to note “normal” tissue colors: red muscle, yellow fat, white
fascia. Fascia should be debrided until clean
healthy tissue remains (see Fig. 33.6 , Case 1)
[ 10 ]. The surgeon should be aware of what lies
at the base of an abdominal wound, and to proceed carefully so that the intra-abdominal contents are not violated. In an acute necrotizing
infection, we do not recommend using methylene blue for the initial debridement; normal tissue colors and vascularized tissue should guide
your debridement in this setting. After the
debridement is complete, a sterile occlusive
dressing or negative pressure wound therapy
should be applied. If viscera is exposed, we recommend using a silastic pouch or Bogota bag
354
Fig. 33.2 Surgical
debridement of an abdominal
wound using a Versajet
(Smith and Nephew.) Note the
normal colors of tissue
throughout the wound: red
muscle, white fascia, and crisp
wound edges
S. Sher and K. Evans
®
Fig. 33.3 Abdominal wound with a sinus tract at the base
Skin surrounding the tract is comprised of unstable scar
with a central non-healing area. This fi gure depicts the
surgeon gently probing the wound with a sterile cotton tip
applicator to evaluate the depth of the tract
Fig. 33.4 A syringe with methylene blue that will be
used to gently inject into the fi stula tract
33 Adjuncts to Wound Healing for Abdominal Wall Wounds
355
Fig. 33.5 ( a ) Abdominal wound with chronic edges
excised, the tract has been injected with methylene blue.
The area that is stained blue should be debrided until the
normal appearance of tissue is seen. Sinus tracts usually
lead to foreign bodies such as mesh or sutures. ( b )
over the bowel, negative pressure wound therapy can then be applied. In addition, postdebridement tissue cultures are obtained which
guide antibiotic regimen as well as whether the
wound is ready to be closed. Closure options
include primary closure, skin grafting , local
fl ap, or free-fl ap reconstruction.
There is some debate over the use of negative
pressure wound therapy in the setting of abdominal wounds, and if the use of negative pressure
wound therapy increases the rate of enterocutaneous or enteroatmospheric fi stula. The highest
rate of fi stula was seen after mesh placement
alone (17.2%) while negative pressure wound
therapy had a fi stula rate of 5.7% [
16 ]. We have
not seen this to be a problem in our treatment
algorithm, which can likely be attributed to early
frequent debridements, the use of biologic mesh
to support fascial closure, and motivation to
achieve soft-tissue closure using local fl aps over
secondary healing.
Wound Care Adjuncts and Dressings
There are numerous factors that help guide clinicians to select appropriate strategies to care for
wounds of the abdominal wall. The size of the
wound, level of contamination, healthcare setting, comfort level and exposed structures are
only a few factors that determine what products
Colonized sutures and all foreign bodies including mesh
must be removed if the wound is infected. ( c ) Patient pre-
sented with small sinus tract, non-healing wound for many
months s/p TRAM fl ap for breast reconstruction. Picture
shows infected overlay synthetic mesh being removed
will be used. If an abdominal wound has exposed
viscera, it is treated in the inpatient setting, usually with a silo, absorbable mesh, dynamic methods, or inert dressing over the viscera. Most
clinicians will then elect to cover this with a negative pressure dressing until the patient can be
returned to the operating room. The temporary
abdominal wall closure should protect the intraabdominal contents, prevent evisceration, assist
in eliminating infection, attempt to preserve
domain, and prevent enterocutaneous fi stula [ 11 ].
Miller et al. has shown that use of negative
pressure wound therapy alone in the acute open
abdomen has been shown to prevent visceral
adherence to the abdominal wall and to maintain traction on the medial fascial edge [ 12 ].
Several studies have shown that adding negative
pressure wound therapy to the treatment regimen for an acute abdominal wound does
decrease the overall number of operations and
decreases the time to closure. If negative pressure therapy is not available, other temporary
closure devices such as the Bogota Bag or
Wittman patch can be used in the acute setting.
A non-adherent layer such as Mepitel, Adaptic,
or the white KCI VAC sponge should be applied
directly over the bowel [ 13 , 14 ].
When negative pressure wound therapy is used
in abdominal wounds, some wound centers are
able to use negative pressure alone or negative
pressure with instillation. When instillation is
356
S. Sher and K. Evans
Fig. 33.6 ( a ) Details of a 74-year-old patient s/p TAH/
BSO for uterine cancer who presented with a draining
wound 7 days after surgery. Note the fat necrosis and fascial separation. ( b ) Marked skin for excisional debride-
ment. All dead and necrotic tissue must be removed. ( c )
All sutures and dead fascia must be removed. ( d ) Fascia is
marked for resection based on color and viability. ( e )
Fascia has been resected and re-closed. ( f ) VAC with
instillation will be used and secondary skin closure will be
considered after deep culture-directed antibiotics have
been started. ( g ) Serial debridements continue until the
wound and fascia look clean and closure can be achieved.
( h ) Two-month postoperative view with healed wound
33 Adjuncts to Wound Healing for Abdominal Wall Wounds
357
added to negative pressure wound therapy, it has
been shown to decrease the number of debridements and decrease the length of hospital stay.
There is early evidence to show that instillation
with polyhexadine solution is more effective than
saline alone when used with negative pressure
wound therapy to combat biofi lm and to decrease
the bacterial burden of wounds. Currently, negative pressure wound therapy with instillation is
only available to inpatients. As a result, if the
patient is being transitioned from the inpatient
setting they would need to use a negative pressure
wound therapy device without instillation [ 11 ].
Negative pressure wound therapy should only be
applied to clean healthy wounds which have been
debrided [ 13 – 16 ] (Fig. 33.7 .) In our practice, if
there is concern for infection or biofi lm we will
initiate negative pressure wound therapy with
instillation between debridements. When the
wound bed appears to be granulating and the cultures are negative we switch to traditional negative pressure wound therapy. We are currently
using Prontosan as our irrigation; the amount of
infi ltrate is determined during the “fi ll” phase
when the sponge begins to appear moistened [ 11 ].
Traditionally, wet to dry dressings were used
to assist in secondary healing of open wounds.
Studies involving lower extremity wound sites
demonstrate a 55% rate of healing by secondary
intention when wet to dry dressings are used
alone, compared to 82.7% rate of healing when
negative pressure wound therapy is used. Wet to
dry dressings can be used between treatment
regimens, if the patient does not have access to
negative pressure wound therapy or if the patient
is unable to tolerate wound therapy or dressing
changes.
Wound Dressings
There are options for local wound care if there is
a soft-tissue defect. However, prior to selecting a
wound dressing one should determine why the
wound is not healing, address any mechanical or
structural issues with the wound bed (biofi lm,
senescent cells), and the wound bed should be
optimized. There has yet to be a single “ideal”
dressing, and no dressing has achieved level I
evidence to be the superior dressing for a given
wound [ 17 ] (see Table 33.1 ).
In general, to promote epithelialization, dressings should: create a moist wound environment,
have factors to promote wound healing, provide
mechanical protection, absorb exudate, allow
gaseous exchange, inhibit microorganisms, and
be cost effective [ 4 , 17 ]. The ideal dressing
should not adhere to the wound, and it should be
able to be changed without pain or trauma to the
patient.
Normal Saline wet to dry dressings can be
applied using gauze or foam. When the two dressings are compared, foam dressings are preferred
to gauze dressings. Foam dressings are less painful, easier to apply, and have higher rates of patient
satisfaction. If there is surface contamination or
Fig. 33.7 ( a ) An example of surgical dehiscence should not
be managed with negative pressure. There is signifi cant
undermining, drainage, and fat necrosis. We recommend
surgical debridement prior to placing negative pressure
wound therapy. ( b ) Entire wound has been debrided and
negative pressure can now be used for wound management
358
Table 33.1 Choosing wound dressing types
Wound characteristic Goal Wound dressing type
Heavily draining wound
Control moisture and
effl uent
Absorptive dressings such as alginates
S. Sher and K. Evans
Superfi cial Bacterial colonization
with odor
Superfi cial wound with granulation
tissue
Control bacterial load Bacteriostatic dressings such as Dakins or
Acetic Acid wet to dry dressings
Promote
epithelialization
Collagen matrix dressing
33 Adjuncts to Wound Healing for Abdominal Wall Wounds
359
odor, ¼ strength Dakin’s or Acetic Acid is recommended. These dressings should be changed twice
per day.
Alginate dressings are another category of dressings that are helpful in abdominal wall wounds.
This class of dressings is extremely absorptive; they
can help prevent maceration of surrounding normal
skin. Alginates are historically fabricated from seaweed products. However, modern dressings are calcium or sodium salts of alginic acid. These dressings
are easily removed and can absorb up to 40 times
their weight in fl uid. They do require a secondary
dressing as an overlay and they must be changed
daily. Some Alginate dressings have silver impregnated into the fi ber that is anti-microbial. Alginate
dressings can be useful in tunneling and undermining wounds, and this is a therapy that we often use
in the outpatient setting for smaller wounds that do
produce an exudate [ 18 ].
The initial goal of wound care is to promote a
healthy wound base with granulation tissue and to
prevent undermining and tunneling. Once granulation tissue is present, collagen matrix dressings
such as Prisma
®
can be used to promote neo-epi-
thelialization and fi nal wound healing [ 19 , 20 ].
Any patient with an abdominal wound should
be closely monitored for fl uid and electrolyte
imbalances, especially if the abdomen is open.
The patient should also be closely managed by a
nutritionist to ensure they are able to meet the
metabolic demands of wound healing. It is also
pertinent that during this period the patients
abstain from smoking to improve oxygen delivery
to tissues. If the patient has other comorbidities
prior to acquiring the abdominal wound, specifi cally diabetes or hypertension, these should be
optimized in order to decrease potential complications [ 6 ].
The majority of abdominal wall wounds can
be closed primarily. When abdominal wall
wounds are closed, our practice often utilizes
incisional negative pressure wound therapy. The
effi cacy in incisional NPWT has been debated in
the literature as to whether it improves healing
time, however in our practice its use has been
shown to limit contamination when an ostomy or
fi stulae are in proximity to the incision [ 13 , 14 ].
If a large soft-tissue defect exists, we recommend closure with local or free-fl ap reconstruction. Some patients are not candidates for a fl ap
or a skin graft , in these rare instances, woundhealing adjuncts can be used. The common biosynthetic dressings which are used in our practice
are Integra
®
or a xenograft. These can be placed
over intact fascia, muscle, or partial soft-tissue
defects (Fig. 33.8 ). Both dressings require that
Fig. 33.8 ( a ) Five-year-old patient with metastatic neu-
roblastoma with history of abdominal compartment syndrome. Negative pressure wound therapy with a
non-adherent sponge or interface was started to create
granulation tissue over bowel. ( b ) After several weeks of
negative pressure wound therapy, signifi cant granulation
tissue formed over the bowel. He is now ready for skin
grafting, however due to comorbidities, xenograft will be
used as an indicator if a skin graft has a high chance of
success. ( c ) Xenograft was used as a temporary dressing
and as an indicator if a skin graft has a high chance of success. The xenograft is left on the wound for 5–7 days, if it
is adherent, then a skin graft can be preformed
360
S. Sher and K. Evans
the bacterial burden of the wound is below 10 3
colony forming units/gram and that the wound
bed is well vascularized. Integra
®
will incorporate into the wound bed, which allows for future
placement of a skin graft. Xenograft is usually
placed in the operating room on a clean wound.
Xenograft adherence to a wound bed is a good
indicator that a skin graft will take. If Integra
®
is
used, we will then cover the incorporated dermal
substitute with a split thickness skin graft
(STSG). The use of STSG in this setting will give
a more stable closure, and when it is healed will
not require wound care. In our practice, we offer
STSG to patients who are not smoking, have
good glycemic control, and have a wound bed
ready to accept a skin graft. We use a Zimmer
®
dermatome to harvest a skin graft which is traditionally 0.012 in. thick. The skin graft is sewn
into place using 5-0 chromic. A layer of mepitel
is then applied followed by negative pressure
wound therapy for 5–7 days. This is commonly
performed on an outpatient basis in our practice.
In conclusion, our approach to wound healing
in abdominal wall defects focuses on early operative debridement and delayed primary closure to
achieve strong fascial and skin healing. Operative
closure can usually be achieved with careful dissection of the abdominal skin fl aps, taking care to
spare perforators to ensure the abdominal skin
fl aps are well perfused. If fascial closure cannot
be achieved, temporary bridges with biologic
mesh and components separation can be
employed with local or free-fl ap skin closure.
However, if the wound cannot be closed, appropriate dressings and careful follow-up of the
progress of the wound will help achieve expeditious wound healing.
References
1. Broughton G, Janis J, Attinger C. A brief history of
wound care. Plast Reconstr Surg. 2006;117:6S–11.
2. Eming S, Krieg T, Davidson J. Infl ammation in wound
repair: molecular and cellular mechanisms. J Invest
Dermatol. 2007;127:514–25.
3. DiPietro L. Wound healing: the role of the macro-
phage and other immune cells. Shock. 1995;4:
233–40.
4. Field C, Kerstein M. Overview of wound-healing in a
moist environment. Am J Surg. 1994;167:S2–6.
5. Singer A, Clark R. Cutaneous wound healing. N Engl
J Med. 1999;341:738–46.
6. Diaz J, Cullianane D, Khwaja K. Eastern Association
for the Surgery of Trauma: management of the open
abdomen, part III—review of abdominal wall reconstruction. J Trauma Acute Care Surg.
2013;75:376–86.
7. Gillespie D, Kistner B, Glass C, et al. Venous ulcer
diagnosis, treatment, and prevention of recurrences.
J Vasc Surg. 2010;52:8S–14.
8. Koolen PG, et al. Patient selection optimization following combined abdominal procedures; analysis of
4925 Patients undergoing panniculectomy/abdominoplasty with or without concurrent hernia repair. Plast
Reconstr Surg. 2014;134:539e–50.
9. James G, Swogger E, Wolcott R, et al. Biofi lms in
chronic wounds. Wound Repair Regen.
2008;16:37–44.
10. Endara M, Attinger C. Using color to guide debridement. Adv Skin Wound Care. 2012;25:549–55.
11. Atema J, Gans S, Boermeester MA. Systemic review
and meta-analysis of the open abdomen and temporary abdominal closure techniques in non trauma
patients. World J Surg. 2015;39(4):912–25.
12. Miller M, Whinney R, McDaniel C. Treating a nonhealing wound with negative pressure wound therapy.
Adv Skin Wound Care. 2008;19:204–5.
13. Roberts D, Zygun D, Grendar M, et al. Negativepressure wound therapy for critically ill adults with
open abdominal wounds; a systemic review. J Trauma
Acute Care Surg. 2012;73:629–40.
14. Kim P, Attinger C, Steinberg J, et al. The impact of
negative-pressure wound therapy with instillation
compared with standard negative-pressure wound
therapy; a retrospective, historical, cohort, controlled
study. Plast Reconstr Surg. 2014;133:709–16.
15. Davis K, Bills J, Barker J, et al. Simultaneous irrigation and negative pressure wound therapy enhances
wound healing and reduces wound bioburden in a porcine model. Wound Repair Regen. 2013;21:869–75.
16. Zannis J, Angobaldo J, Marks M. Comparison of fasciotomy wound closures using traditional dressing
changes and the vacuum assisted closure device. Ann
Plast Surg. 2009;62:407–9.
17. Vermeulen H, Ubbink D, Goossens A, et al. Dressings
and topical agents for surgical wounds healing by secondary intention. Cochrane Database Syst Rev.
2004;2:CD003554.
18. Gove J, Hampton S, Smith G. Using the exudate decision algorithm to evaluate wound dressings. Br
J Nurs. 2014;23:S26–9.
19. Ding X, Shi L, Liu C. A randomized comparison
study of Aquacel Ag and Alginate Silver as skin graft
donor site dressings. Burns. 2013;39:1547–50.
20. Durnville J, Deshpande S, O’Meara S. Hydrocolloid
dressings for healing diabetic foot ulcers. Cochrane
Database Syst Rev. 2013;8:CD009099.
Loss of Abdominal Domain:
Defi nition and Treatment
Strategies
Gregory J. Mancini and Hien N. Le
3 4
D e fi nition
“Loss of domain” is not well defi ned in the literature. It is most commonly described as a large
abdominal wall hernia with a signifi cant amount
of abdominal content herniated through the
abdominal wall into a hernia sac that forms a secondary abdominal cavity. Some defi ne loss of
domain by the amount of abdominal content outside the abdominal cavity, with as little as
15–50% or greater. Chevrel described it in 1987
as abdominal ventral hernias whose contents
were held in place by adhesions and not reducible, thus losing their “right of domain.”
Figure 34.1 is a cross-sectional image of an
abdominal CT scan demonstrating a loss of
domain hernia. Regardless, the primary abdominal cavity is unable to accommodate the viscera
without prohibitively high intra-abdominal pressures. If herniated contents are diffi cult to reduce
below the level of the fascia when the patient is in
supine position during physical exam, loss of
domain should be suspected. We routinely use
Computed Tomography (CT) to further evaluate
G. J. Mancini , M.D., F.A.C.S. (*) • H. N. Le , M.D.
University of Tennessee Graduate School of
Medicine, University of Tennessee Medical Center,
Knoxville , 1924 Alcoa Highway, Box U-11 ,
Knoxville , TN 37290 , USA
gmancini@mc.utmck.edu;
e-mail:
hlei@mc.utmck.edu
and defi ne the anatomy. Most experts agree that
loss of domain requires specialized strategies for
successful repair.
Physics of LOD
Cylinder Concept
The abdomen can be described as a cylinder with
a fairly uniform internal pressure. The anterior
abdominal wall is made up of the rectus muscles
that connect in the midline at the linea alba. The
lateral abdominal wall is formed by the external
oblique, internal oblique, transversus abdominis,
and their aponeuroses fuse at the lateral border of
the rectus abdominis to form the semilunar line.
The posterior abdominal wall is relatively rigid,
formed by the spine and erector spinae muscles.
The rectus abdominis muscles are the principal
fl exors of the anterior abdominal wall and stabilize the pelvis while walking. The lateral abdominal wall muscles, all with different vectors of
movement, work in conjunction to rotate and laterally fl ex the spine. Their overall direction of
pull is to distract from the midline. The erector
spinae muscles extend the vertebral column.
Together, the abdominal muscles work through
coupling to stabilize the torso and allow coordinated movement and weight shifts [ 1 ]. The top of
the cylinder is the diaphragm muscle and the bottom of the cylinder is the pelvic fl oor. When
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_34
361© Springer International Publishing Switzerland 2016
362
G.J. Mancini and H.N. Le
Fig. 34.1 A cross-sectional image of an abdominal CT
scan demonstrating a loss of domain hernia
simultaneously contracted, they function to
increase abdominal pressure, which facilitates
expiration, micturition, defecation, and even
parturition .
Broken Cylinder Concept
When a hernia develops, and in particular a
loss of domain exists, there is lack of confi nement of the intra- abdominal contents within
the cylinder, resulting in signifi cant viscera
outside the abdominal domain and low intraabdominal pressure. The linea alba is no longer
connecting the rectus abdominis muscles in the
midline, breaking the cylinder. The lateral
abdominal muscles are no longer mechanically
coupled, altering their functionality. As the lateral abdominal muscles foreshorten, they
retract the rectus muscles rendering them ineffective in increasing intra-abdominal pressure.
The pressure normally generated with the
action instead decompresses into the lowpressure hernia sac. CT scans often demonstrate a foreshortening of the oblique muscles.
This broken cylinder results in many morbid
conditions, as described next.
Morbidity of Loss of Domain
Loss of domain is often a morbid condition.
Patients usually have poor overall quality of life
with many complaints, including postural musculoskeletal dysfunction, chronic gastrointestinal
and genitourinary pathology, pulmonary dysfunction, and psychosocial issues. As described
previously, the abdominal musculature is vital for
upper and lower body activity, allowing coordinated movement, weight shifts, and stabilization
during physical activity. Normally, torso stability
is maintained by two columns, the erector spinae
muscles posteriorly and the rectus abdominis
muscles anteriorly. When the linea alba is disrupted, the rectus abdominis muscles become
dysfunctional, and the columns are mechanically
uncoupled. This results in greater pressure on the
posterior column, leading to chronic back pain
and spine curvature disorders.
Chronic gastrointestinal and genitourinary
pathology can develop due to the inability to
increase intra-abdominal pressures. Simple
bodily functions such as defecation and micturition can become much more diffi cult leading to
constipation and overfl ow urinary incontinence.
Chronic intestinal incarceration is also common
due to the usual complicated surgical history with
formation of adhesions, causing pain and other
obstructive symptoms.
Pulmonary dysfunction is also a major problem
because the abdominal wall plays an accessory role
to the intercostal muscles, thorax, and diaphragm
in respiration. The abdominal wall primarily functions in forced expiration with the lateral abdominal muscles to raise intra- abdominal pressure
during exercise to meet increased demands of
breathing. The increased pressure is transmitted
through the diaphragm to the thorax and forces air
from the lungs. With a dysfunctional abdominal
wall, forced expiration is decreased. This will not
only affect exercise tolerance, but also simple
functions as coughing and clearing secretions.
These problems often combine leading to
decreased mobility and increased obesity. This usually only worsens the existing issues, increasing the
hernia size, and in turn causing more strain on the